Directly observed antiretroviral therapy eliminates adverse effects of active drug use on adherence

Syndemic conditions and medication adherence in older men living with HIV who have sex with men

For people living with HIV, lack of adherence to antiretroviral therapy (ART) is a serious problem and frequently results in HIV disease progression. Reasons for non-adherence include concomitant psychosocial health conditions – also known as syndemic conditions – such symptoms of depression or posttraumatic stress disorder (PTSD), past physical or sexual abuse, intimate partner violence (IPV), stimulant use, and binge drinking. The aim of this study was to investigate the association between syndemic conditions and medication adherence. The sample included 281 older men living with HIV who have sex with men (MSM). The study period was December 2012–July 2016. We observed the following syndemic conditions significantly decreased medication adherence: symptoms of depression (p = .008), PTSD (p = .002), and stimulant use (p < .0001). Past physical or sexual abuse, IPV, and binge drinking were not significantly associated with decreased medication adherence. The findings suggest that syndemic conditions may impact medication adherence in older MSM living with HIV.

Dispensation of antiretroviral therapy and methadone maintenance therapy at the same facility in a low-barrier setting linked to optimal adherence to HIV treatment

OBJECTIVES

We sought to examine the association between dispensation of methadone maintenance therapy (MMT) and antiretroviral therapy (ART) at the same facility, across multiple low-barrier dispensing outlets, and achieving optimal adherence to ART among people who use illicit drugs (PWUD).

METHODS

We used data from the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS) study, a long-running study of a community-recruited cohort of HIV-positive PWUD, linked to comprehensive HIV clinical records in Vancouver, Canada, a setting of no-cost, universal access to HIV care. The longitudinal relationship between MMT-ART dispensation at the same facility and the odds of ≥ 95% ART adherence was analysed using multivariable generalized linear mixed-effects modelling. We conducted a further analysis using a marginal structural mode with inverse probability of treatment weights as a sensitivity analysis.

RESULTS

This study included data on 1690 interviews of 345 ART- and MMT-exposed participants carried out between June 2012 and December 2017. In the final multivariable model, MMT-ART dispensation, compared with nondispensation at the same facility, was associated with greater odds of achieving ≥ 95% adherence [adjusted odds ratio (AOR) 1.56; 95% confidence interval (CI) 1.26-1.96]. A marginal structural model estimated a 1.48 (95% CI 1.15-1.80) greater odds of ≥ 95% adherence among participants who reported MMT-ART dispensation at the same facility compared with those who did not.

CONCLUSIONS

The odds of achieving optimal adherence to ART were 56% higher during periods in which MMT and ART medications were dispensed at the same facility, in a low-barrier setting. Our findings highlight the need to consider a simpler integrated approach with medication dispensation at the same facility in low-threshold settings.

A systematic review of community-based interventions to improve oral chronic disease medication regimen adherence among individuals with substance use disorder

BACKGROUND

Poor medication adherence has been shown to cause medical complications, death, and increased healthcare costs and may be of particular importance in patients with substance use disorder (SUD). Concerns regarding adherence in this population may influence a healthcare provider's decision to prescribe a medication requiring high adherence. Guidance defining best practices that promote adherence among individuals with SUD is lacking.

METHODS

A review of English articles in Medline and PsycINFO databases, published between October 1, 1994 and October 31, 2017, was conducted in order to identify studies of interventions intended to improve adherence to oral chronic disease medication regimens among patients with SUD. Randomized controlled trials, quasi-experimental study designs, and case series were included. Article quality was assessed.

RESULTS

A total of 854 abstracts were retrieved, of which 24 met inclusion criteria. Adherence interventions were categorized as those: 1) addressing the chronic disease state; 2) addressing SUD; or 3) both. Studies varied greatly with respect to intervention length, method of measuring adherence, and quality. Statistically significant improvement in adherence was observed in 12 of 24 studies (50%). Specific interventions that improved adherence included incentive-based interventions, directly observed therapy, and telephonic/home visits. Counseling-based interventions such motivational interviewing and cognitive behavioral therapy presented mixed results.

CONCLUSIONS

While effective interventions were identified, heterogeneity of study designs and study quality preclude determination of optimal interventions to promote adherence in this population. Further evaluation with sound study design may inform the development of best practices for treating chronic disease in patients with SUD.

Challenges in the Evaluation of Interventions to Improve Engagement Along the HIV Care Continuum in the United States: A Systematic Review

In the United States (US), there are high levels of disengagement along the HIV care continuum. We sought to characterize the heterogeneity in research studies and interventions to improve care engagement among people living with diagnosed HIV infection. We performed a systematic literature search for interventions to improve HIV linkage to care, retention in care, reengagement in care and adherence to antiretroviral therapy (ART) in the US published from 2007-mid 2015. Study designs and outcomes were allowed to vary in included studies. We grouped interventions into categories, target populations, and whether results were significantly improved. We identified 152 studies, 7 (5%) linkage studies, 33 (22%) retention studies, 4 (3%) reengagement studies, and 117 (77%) adherence studies. 'Linkage' studies utilized 11 different outcome definitions, while 'retention' studies utilized 39, with very little consistency in effect measurements. The majority (59%) of studies reported significantly improved outcomes, but this proportion and corresponding effect sizes varied substantially across study categories. This review highlights a paucity of assessments of linkage and reengagement interventions; limited generalizability of results; and substantial heterogeneity in intervention types, outcome definitions, and effect measures. In order to make strides against the HIV epidemic in the US, care continuum research must be improved and benchmarked against an integrated, comprehensive framework.

Developing an Integrated, Brief Biobehavioral HIV Prevention Intervention for High-Risk Drug Users in Treatment: The Process and Outcome of Formative Research

To date, HIV prevention efforts have largely relied on singular strategies (e.g., behavioral or biomedical approaches alone) with modest HIV risk-reduction outcomes for people who use drugs (PWUD), many of whom experience a wide range of neurocognitive impairments (NCI). We report on the process and outcome of our formative research aimed at developing an integrated biobehavioral approach that incorporates innovative strategies to address the HIV prevention and cognitive needs of high-risk PWUD in drug treatment. Our formative work involved first adapting an evidence-based behavioral intervention-guided by the Assessment-Decision-Administration-Production-Topical experts-Integration-Training-Testing model-and then combining the behavioral intervention with an evidence-based biomedical intervention for implementation among the target population. This process involved eliciting data through structured focus groups (FGs) with key stakeholders-members of the target population (n = 20) and treatment providers (n = 10). Analysis of FG data followed a thematic analysis approach utilizing several qualitative data analysis techniques, including inductive analysis and cross-case analysis. Based on all information, we integrated the adapted community-friendly health recovery program-a brief evidence-based HIV prevention behavioral intervention-with the evidence-based biomedical component [i.e., preexposure prophylaxis (PrEP)], an approach that incorporates innovative strategies to accommodate individuals with NCI. This combination approach-now called the biobehavioral community-friendly health recovery program-is designed to address HIV-related risk behaviors and PrEP uptake and adherence as experienced by many PWUD in treatment. This study provides a complete example of the process of selecting, adapting, and integrating the evidence-based interventions-taking into account both empirical evidence and input from target population members and target organization stakeholders. The resultant brief evidence-based biobehavioral approach could significantly advance primary prevention science by cost-effectively optimizing PrEP adherence and HIV risk reduction within common drug treatment settings.

Highly specific reasons for nonadherence to antiretroviral therapy: results from the German adherence study

BACKGROUND

Reasons for and frequency of nonadherence to antiretroviral therapy (ART) may have changed due to pharmacological improvements. In addition, the importance of known non-pharmacologic reasons for nonadherence is unclear.

METHODS

We performed a cross-sectional, noninterventional, multicenter study to identify current reasons for nonadherence. Patients were categorized by physicians into the following adherence groups: good, unstable, or poor adherence. Co-variables of interest included age, sex, time since HIV diagnosis, ART duration, current ART regimen, HIV transmission route, comorbidity, HIV-1 RNA viral load (VL), and CD4 cell count. Patients self-reported the number of missed doses and provided their specific reasons for nonadherent behavior. Statistical analyses were performed using Fisher's extended exact test, Kruskal-Wallis test, and logistic regression models.

RESULTS

Our study assessed 215 participants with good (n=162), unstable (n=36), and poor adherence (n=17). Compared to patients with good adherence, patients with unstable and poor adherence reported more often to have missed at least one dose during the last week (good 11% vs unstable 47% vs poor 63%, p<0.001). Physicians' adherence assessment was concordant with patients' self-reports of missed doses during the last week (no vs one or more) in 81% cases. Similarly, we found a strong association of physicians' assessment with viral suppression. Logistic regression analysis showed that "reduced adherence" - defined as unstable or poor - was significantly associated with patients <30 years old, intravenous drug use, history of acquired immune deficiency syndrome (AIDS), and psychiatric disorders (p<0.05). Univariate analyses showed that specific reasons, such as questioning the efficacy/dosing of ART, HIV stigma, interactive toxicity beliefs regarding alcohol and/or party drugs, and dissatisfaction with regimen complexity, correlated with unstable or poor adherence (p<0.05).

CONCLUSION

Identification of factors associated with poor adherence helps in identifying patients with a higher risk for nonadherence. Reasons for nonadherence should be directly addressed in every patient, because they are common and constitute possible adherence intervention points.

Health outcomes and retention in care following release from prison for patients of an urban post-incarceration transitions clinic

Chronic health conditions are overrepresented among prisoners who often face barriers to medical care following release. Transitions clinics seek to provide timely access to medical care following release. This retrospective cohort study investigated care delivery and health outcomes for recently released prisoners receiving care at the Bronx Transitions Clinic. Among 135 recently released prisoners, median time from release to initial medical visit was 10 days (IQ Range: 5-31). Six-month retention in care was high for HIV-infection (86%), but lower for opioid dependence (33%), hypertension (45%) and diabetes (43%). At six months, 54% of HIV-patients had a suppressed viral load, but fewer buprenorphine-treated patients reduced opioid use (19%), and fewer hypertensive and diabetic patients reached respective blood pressure (35%) and hemoglobin A1c (14%) goals. Access to medical care is necessary but not sufficient to control chronic health conditions. Additional interventions are necessary for formerly incarcerated people to achieve optimal health outcomes.

Finding what works: identification of implementation strategies for the integration of methadone maintenance therapy and HIV services in Vietnam

Background

Integration of methadone maintenance therapy (MMT) and HIV services is an evidence-based intervention (EBI) that benefits HIV care and reduces costs. While MMT/HIV integration is recommended by the World Health Organization and the Centers for Disease Control and Prevention, it is not widely implemented, due to organizational and operational barriers. Our study applied an innovative process to identify implementation strategies to address these barriers.

Methods

Our process was adapted from the Expert Recommendations for Implementing Change (ERIC) protocol and consisted of two main phases. In Phase 1, we conducted 16 in-depth interviews with stakeholders and developed matrices to display barriers to integration. In Phase 2, we selected implementation strategies that addressed the barriers identified in Phase 1 and conducted a poll to vote on the most important and feasible strategies among a panel with expertise in cultural context and implementation science.

Results

Barriers fell into two broad categories: policy and programmatic. At the policy level, barriers included lack of a national mandate, different structures (MMT vs. HIV clinic) for cost reimbursement and staff salaries, and resistance on the part of staff to take on additional tasks without compensation. Programmatic barriers included the need for cross-training in MMT and HIV tasks, staff accountability, and commitment from local leaders. In Phase 2, we focused on programmatic challenges. Based on voting results and iterative dialogue with our expert panel, we selected several implementation strategies in the domains of technical assistance, staff accountability, and local commitment that targeted these barriers.

Conclusions

Key programmatic barriers to MMT/HIV integration in Vietnam may be addressed through implementation strategies that focus on technical assistance, staff accountability, and local commitment. Our process of identifying implementation strategies was simple, low cost, and potentially replicable to other settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0420-8) contains supplementary material, which is available to authorized users.

Effect of integrating HIV and addiction care for non-engaging HIV-infected opiate-dependent patients

BACKGROUND

HIV-positive substance dependent patients contribute disproportionally to HIV morbidity and mortality as a result of poor compliance with their HIV treatment. For HIV-positive opiate-dependent patients integrating HIV and addiction care improves HIV morbidity but the effect on addiction morbidity is not known.

AIMS

This study aims to establish if integrating HIV and addiction care has a significant effect on addiction and HIV morbidity for non-engaging HIV-positive opiate-dependent patients.

METHODS

Patients attending the National Drug Treatment Centre who had disengaged from their HIV treatment in St James's Hospital were recruited to receive HIV care integrated into their methadone maintenance programme. Outcome was investigated in terms of urine toxicology (opiates, cocaine, cannabis and amphetamines); adherence to methadone; proportion receiving directly observed antiretroviral therapy; proportion HIV virally suppressed; and the CD4 cell count.

RESULTS

No significant change in substance use or methadone adherence was demonstrated in the 19 recruited participants. There was a significant increase in the proportion receiving directly observed antiretroviral therapy, and in the CD4 cell count.

CONCLUSION

Integration of HIV and addiction care optimises the physical health of non-engaging HIV-positive opiate-dependent patients with no substantial effect on their methadone maintenance programme.

Integrating antiretroviral therapy in methadone maintenance therapy clinics: service provider perceptions

BACKGROUND

Using methadone maintenance therapy (MMT) clinics to deliver antiretroviral therapy (ART) is an effective strategy to promote treatment initiation and adherence for HIV-positive drug users. This paper describes the implementation barriers perceived by service providers for an intervention pilot designed to integrate ART services in MMT clinics.

METHODS

The study was conducted in six MMT clinics in Sichuan province, China. Two service providers selected from each of the six clinics underwent training in administering ART. The trained providers delivered ART-related services in their clinics. A focus group was conducted among the service providers to assess their experiences and perceived challenges in delivering integrated services.

RESULTS

Barriers at policy, institutional, provider, and client levels were identified. Policy level barriers included household registration restrictions and a lack of insurance coverage for testing expenses. Inefficient coordination between treatment sites and MMT clinics was an obstacle at the institutional level. Insufficient training and added workload were barriers at the provider level. Finally, conflict with daily dosing habits was identified as the primary reason that clients did not accept ART.

CONCLUSION

Although integrating ART into MMT clinics is beneficial, multilevel barriers to implementation need to be addressed. This study documents the need for treatment transferability and insurance coverage, protection of client confidentiality, proper provider training, coordination with treatment sites, and individualized ART service for MMT clients.

Gender moderates the influence of psychosocial factors and drug use on HAART adherence in the context of HIV and childhood sexual abuse

This study aimed to examine gender moderation within a stress and coping model of HIV medication adherence in adults with a history of childhood sexual abuse (CSA). Sequelae of CSA, including negative coping, psychological distress, and drug use, interfere with adherence to highly active antiretroviral treatment (HAART). These obstacles to adherence are likely moderated by gender. Gender may particularly influence the mediational effect of drug use on adherence. Participants included 206 adults living with HIV/AIDS and CSA. Categorical/continuous variable methodology in a structural equation modeling framework was used to test a multigroup model with women and men. Gender significantly moderated several effects in the model. For women, the effect of psychological distress on HAART adherence was mediated by drug use and the effect of drug use on viral load was mediated by HAART adherence. Among men, drug use did not significantly impact adherence. Since gender appears to moderate the effect of drug use on medication adherence, it is particularly important to address drug use within the context of HIV disease management in women with a history of CSA. Further, interventions to increase HAART adherence should take trauma history, gender, and drug abuse into account when assessing efficacy.

Mortality among methadone maintenance clients in China: a six-year cohort study

Objective

To assess the overall mortality of methadone maintenance treatment (MMT) clients in China and its associated factors.

Methods

A total of 1,511 MMT clients, all of whom enrolled in China's first eight MMT clinics between March and December 2004, were included in this cohort study and followed for approximately six years, until June 2010. Mortality and its predictors were examined using Cox proportional hazards regression models.

Results

A total of 154 deaths were observed within 5,391 person-years (PY) of follow-up for an all-cause mortality rate of 28.6 per 1,000 PY. The leading causes of death were drug overdose (33.8%), HIV/AIDS-unrelated disease (21.4%), and HIV/AIDS (16.9%). The all-cause mortality rate of clients engaged in MMT for one year or less was roughly three times that of clients who stayed in MMT for four years or more (14.0 vs. 4.6, p<0.0001), HIV-positive subjects was nearly four times mortality rate than that of HIV-negative individuals (28.1 vs.6.8, p<0.0001). ART-naive HIV-positive subjects had approximately two times higher mortality rate than those receiving ART (31.2 vs. 17.3, <0.0001). After adjusting for confounding variables, we found that being male (HR = 1.63, CI: 1.03–2.57, p = 0.0355) and being HIV-positive (HR = 5.16, CI: 3.70–7.10, p<0.0001) were both associated with higher risk of death whereas increased durations of methadone treatment were associated with a lower risk of death (HR = 0.26, CI: 0.18–0.38, p<0.0001 for two to three years, HR = 0.08, CI: 0.05–0.14, p<0.0001 for four or more years).

Conclusion

Overall mortality was high among MMT clients in China. Specific interventions aimed at decreasing mortality among MMT clients are needed. Our study supports the need for keeping client at MMT longer and for expanding ART coverage and suggests the potential benefits of integrated MMT and ART services for drug users in China.

Drug induced increases in CNS dopamine alter monocyte, macrophage and T cell functions: implications for HAND

Central nervous system (CNS) complications resulting from HIV infection remain a major public health problem as individuals live longer due to the success of combined antiretroviral therapy (cART). As many as 70 % of HIV infected people have HIV associated neurocognitive disorders (HAND). Many HIV infected individuals abuse drugs, such as cocaine, heroin or methamphetamine, that may be important cofactors in the development of HIV CNS disease. Despite different mechanisms of action, all drugs of abuse increase extracellular dopamine in the CNS. The effects of dopamine on HIV neuropathogenesis are not well understood, and drug induced increases in CNS dopamine may be a common mechanism by which different types of drugs of abuse impact the development of HAND. Monocytes and macrophages are central to HIV infection of the CNS and to HAND. While T cells have not been shown to be a major factor in HIV-associated neuropathogenesis, studies indicate that T cells may play a larger role in the development of HAND in HIV infected drug abusers. Drug induced increases in CNS dopamine may dysregulate functions of, or increase HIV infection in, monocytes, macrophages and T cells in the brain. Thus, characterizing the effects of dopamine on these cells is important for understanding the mechanisms that mediate the development of HAND in drug abusers.

The potential uses of preexposure prophylaxis for HIV prevention among people who inject drugs

PURPOSE OF REVIEW

Oral preexposure prophylaxis (PrEP) has shown HIV preventive efficacy for several key populations at risk for HIV infection including MSM and heterosexual men and women in HIV serodiscordant relationships. An efficacy trial of daily oral tenofovir among people who inject drugs (IDU) is underway in Thailand.

RECENT FINDINGS

Although efficacy data is pending, there is emerging biological and public health plausibility data suggesting the utility of PrEP as an effective component of combination HIV prevention for IDU. Drawing from studies characterizing adherence to antiretroviral therapy for IDU, there are a range of scientific and operational considerations for the potential use of PrEP for IDU. We review here the available literature on the potential use of PrEP for IDU, barriers to uptake and adherence, and potential implementation science questions, which could address, and potently increase, the effectiveness of this intervention.

SUMMARY

IDU remain the most underserved population in the HIV response worldwide, and have a marked gap in prevention services, making PrEP a potentially promising addition to the prevention toolkit for people who use drugs and, for those already living with HIV infection, for their spouses and other sexual partners.

A family history of substance dependence obscures the group differences in brain function associated with HIV-1 and ART

BACKGROUND

Recently, the NIH called for additional research on the topic of viral and host factors contributing to impaired cognitive and neural function in HIV/AIDS patients and their response to antiretroviral treatment. This investigation responds to that call by examining a host factor, a family history of substance dependence, often overlooked in cognitive and neuroimaging studies of HIV/AIDS.

METHODS

We categorized 146 HIV-1 seropositive patients receiving antiretroviral treatment (ART) and 92 seronegative volunteers by the presence or absence of alcohol, cocaine, or heroin dependence affecting a biological parent. Seropositive patients were further categorized by the estimated ability of their individual ART regimens to penetrate the CNS. The indicator of brain function was a 3-7Hz oscillatory electroencephalographic response (theta ERO) evoked by target stimuli presented during a simple selective attention task.

RESULTS

The analysis revealed that the presence of a family history of substance dependence obscured the reduction in frontal theta ERO power accompanying the presence of HIV-1 as well as the improvement in frontal theta ERO power accompanying treatment with ART agents estimated to have greater (n=41) versus lesser (n=105) CNS penetrance. Secondary analyses employing sLORETA source localization techniques revealed that the source of the theta ERO response was similarly reduced by the presence of either HIV-1 or a family history of substance dependence.

CONCLUSIONS

We conclude that a family history of substance dependence complicates and obscures the subtle neurophysiological changes which typically accompany HIV/AIDS and ART. Studies of new therapeutic agents for HIV-1-associated cognitive and neurophysiological impairments must consider this complication and exclude or control it.